If'      ^^^tAJiA  jr^af      rJ. 


HX00019348 


LECTURES 


GYNECOLOGICAL     NURSING 


DELIVERED  BY 


EDWARD  J.  ILL,  M.D„ 


NURSES  OF  ST.   BARNABAS  HOSPITAL 


NEWARK,  NEW  JERSEY. 


REPORTED    BY 

MISS    ELLEN    F.    CONNINGTON. 


NEWARK,  N.   J.: 
John  C.  SciiErxER,  Hook  Binder  and  Printer. 


LECTURES 


GYNECOLOGICAL     NURSING 


DELIVERED   BY 


EDWARD  J.  ILL,  M.D., 


NURSES   OF  ST.  BARNABAS  HOSPITAL 


NEWARK,  NEW  JERSEY. 


REPORTED   BY 


MISS   ELLEN   F.    CONNINGTON. 


NEWARK,  N.  J.  : 
John  C.  Schei.ler,  Ijook  Binbek  and  Printer. 


PRKKACK. 


The  contents  of  this  pamphlet  represents  very  well  the 
lectures  delivered  by  the  undersigned  to  the  nurses  of  St. 
Barnabas  Hospital  during  the  winter  of  1900-1901. 

I  am  sure  these  ''Notes"  will  be  of  use  to  those  for 
whom  they  are  intended.  I  have  purposely  refrained  from 
any  theoretical  talk.  Our  lectures  to  nurses  should  be  of 
the  simplest  and  most  practical  character.  The  nurse 
should  not  be  encumbered  with  things  that  she  cannot 
understand,  or  which  are  useless  to  her  in  the  practical 
work  of  her  calling. 

Miss  Connington  deserves  much  praise  for  the  spirit 
with  which  she  has  collected  these  notes  and  published 
them. 

EDWARD  J.  ILL. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/lecturesongynecoOOille 


LECTUEE  I. 

We  expect  that  a  nurse  who  listens  to  a  lecture  on  gyne- 
cological nursing  should  have  had  some  experience  and  some 
knowledge  as  to  general  nursing,  dietetics,  baths,  etc.  These 
things  Avill,  therefore,  not  be  touched  upon  in  these  lectures. 

By  gynecology  we  mean  a  study  of  the  diseases  peculiar  to 
women.  I  will  incjude  in  my  lectures  to  you  the  nursing  of 
diseases  of  the  rectum,  breast  and  the  bladder  of  the  female. 

The  anatomy  of  the  female  pe,lvis  and  its  contents  inter- 
est the  nurse  only  so  far  as  it  is  necessary  for  her  to  under- 
stand such  manipulations  as  she  will  be  called  upon  to  per- 
form. For  that  reason  I  will  not  detain  you  by  a  long  and 
minute  detail  of  the  structures. 

We  shall  study  the  anatomy  under  five  headings: 

First — The  anatomy  of  the  bony  pelvis. 

Second — The  external  genitals. 

Third — The  internal  genitals. 

Fourth — The  rectum. 

Fifth — The  bladder  and  urethra. 

The  bony  pelvis  consists  of  four  bones,  the  two  innominata 
and  the  sacrum  with  its  elongation,  called  the  coccyx. 

The  innominate  bone  is  divided  into  three  distinct  portions, 
the  i,lium,  the  ischium  and  the  pubes,  which  remain  separated 
from  each  other  up  to  and  even  beyond  the  period  of  puberty, 
but  later  unite  into  one  strong  bone. 

The  pelvic  bones  are  connected  one  to  the  other  by  strong 
ligaments.  Between  the  pubic  bones  in  front  and  the  sacrum 
and  the  ilium  in  the  back  there  is  a  heavy  layer  of  fibro-carti- 
lage  which  permits  a  slight  motion  of  these  parts.  The  pelvis 
forms  a  structure  which  is  intended  to  protect  from  injury, 
through  external  violence,  the  many  important  organs  it  con- 
tains, while  it  forms,  at  the  same  time,  a  support  for  the  other 
intra-abdominal  organs.  In  its  shape,  in  the  woman  it  is  shal- 
lower and  wider  than  in  the  man.  This  is  for  the  purpose  of 
permitting  the  passage  of  the  child. 

By  the  external  genitals  we  mean  those  parts  which  can 
be  seen  by  an  inspection  from  outside  on  separating  those  two 
folds  of  skin  called  the  labia  majora.  In  the  normal  condition, 
with  the  thighs  slightly  abducted  and  flexed  on  the  abdomen, 
these  two  large  folds  of  skin  should  cover  the  more  delicate 
structures  of  the  vulva.  When  the  female  ha.s  arrived  at 
puberty  the  outei'  and  upper  portion  of  the  labia  majora  are 
covered  with  short  crisj)  hair.     Within  the  large  lips  there 


arises  just  below  the  upper  portion  tlie  labia  minora,  runninji^ 
a  downward  and  outward  course.  They  lose  themselves  just 
above  and  to  the  outer  side  of  the  opening  into  the  vagina. 
These  folds,  like  those  of  the  labia  majora,  are  formed  of  skin. 

As  the  labia  minora  are  separated  we  see  within  its  upper 
borders  a  triangular  space  called  the  vestibule,  which  is  cov- 
ered by  a  pale  pink  mucous  membrane.  In  the  lower  portion 
of  this,  that  is  in  the  base  of  the  triangle,  we  see  a  small  tri- 
angular slit,  which  is  the  opening  into  urethra,  and  is  called 
the  meatus  urinarius.  This  triangular  orifice  appears  in  this 
shape  normally  in  the  virgin;  in  the  married  woman  and  in  the 
woman  who  has  borne  children  the  urethral  opening  is  no 
longer  of  a  triangular  shape,  but  becomes  roundish. 

Within  the  labia  minora  we  also  find  an  opening  of  various 
shapes.  In  the  virgin  it  is  either  round,  semi-lunar  or  divided 
into  several  openings  by  strips  of  mucous  membrane  usually 
running  in  an  anterior  and  posterior  direction.  This  opening 
is  called  the  ostium  of  the  vagina,  or  the  opening  to  the  vagina, 
and  is  formed  by  a  duplicature  of  mucous  membrane. 

In  the  married  woman  and  in  the  woman  who  has  had  chil- 
dren this  delicate  membrane  is  dilated  and  torn,  so  that  it  wi,ll 
often  appear  in  the  shape  of  small  bits  of  mucous  membrane 
fringing  the  opening  to  the  vagina.  Below  the  ostium  vaginae 
we  have  that  space  running  as  far  as  the  anus,  which  is  called 
the  perineum. 

As  we  look  into  the  ostium  vaginae  we  can  observe  a  canal 
lined  by  mucous  membrane,  running  in  a  curved  direction  up- 
ward and  backward,  with  a  slight  concavity  forward.  It  has 
many  folds.  It  is  from  two  and  one-half  inches  in  its  anterior 
wall  to  three  and  one-half  inches  in  its  posterior  wal,l  in 
length.  This  canal  is  formed  by  various  muscular  layers  and 
lined  on  its  inner  surface  by  a  mucous  membrane.  It  forms 
the  connecting  link  between  the  internal  genitals  and  the  ex- 
ternal genitals,  and  is  called  The  vagina.  Under  normal  con- 
ditions the  wajls  fall  together,  assuming  the  form  of  the  let- 
ter X 

This  brings  us  to  a  discussion  of  the  internal  genitals  and 
will  not  detain  us  long,  as  they  are  of  very  little  practical 
value  to  the  nurse  in  the  exercise  of  her  duties. 

Where  the  vagina  terminates  it  surrounds  the  lower  por- 
tion of  a  strong  muscular  organ,  called  the  uterus.  That  por- 
tion which  projects  into  the  vagina  is  knoAvn  as  the  vaginal 
portion  of  the  uterus.  This  is  but  a  portion  of  the  neck  of  the 
uterus,  so  called  for  it  extends  upward  for  a  little  over  an  inch 
in  the  unmarried  woman  and  forms  about  one-half  of  the 
whole  length  of  this  organ.  From  the  internal  opening  of  the 
uterus,  upward,  we  have  the  body  of  the  organ.    The  length  of 


the  whole  uterus  is  about  two  and  one-half  inches  in  the  nulli- 
parous  woman  and  from  two  and  three-quarters  to  three 
inches  in  the  multiparous  woman;  its  cavity  is  lined  by  a 
mucous  membrane  and  starts  as  a  small  opening  in  the  vaginal 
portion,  extending  upward  in  a  fusiform  shape  unti,l  it  reaches 
the  internal  opening,  where  there  is  a  decided  contraction. 
Above  this  the  cavity  takes  on  a  triangular  shape.  The  upper 
lateral  portion  of  the  cavity  being  continuous  with  the  cavity 
of  the  oviducts  or  Fallopian  tubes.  It  is  in  this  large  tri- 
angular cavity  that  the  egg  finds  its  lodgment  and  the  child 
grows  to  full  term.  It  is  also  this  portion  of  the  uterus  that 
develops  so  wonderfully  during  pregnancy.  Its  strong  mus- 
cular wa,lls  assist  to  a  marked  degree  in  expelling  the  child 
into  the  outer  world. 

The  uterus  is  situated  in  the  upper  portion  of  the  lesser 
cavity  of  the  pelvis  between  the  bladder  in  front  and  the  rec- 
tum behind.  It  is  a  very  movable  organ.  The  uterus  is  held 
in  its  position  in  the  pelvis  by  duplicatures  of  peritoneum 
covering  cellular  tissue  of  great  elasticity  and  considerable 
strength.  Within  the  folds  of  this  peritoneum  can  also  be 
found  some  muscular  tissue,  vessels,  nerves  and  the  lymphat- 
ics. These  duplicatures  are  called  ligaments,  of  which  there 
i«re  three  important  ones  on  each  side:  The  utera-sacral,  pos- 
ter! orily  the  lateral  or  broad  ligaments  on  either  side,  and  the 
round  ligaments  in  front. 

Besides  the  vessels,  nerves  and  lymphatics  in  the  broad 
ligaments  we  find  the  ovary  and  the  Fallopian  tube.  The 
Fallopian  tubes  are  lined  with  mucous  membrane,  and  they 
originate  in  both  upper  and  lateral  portions  of  the  uterus, 
extending  outward  for  about  four  and  one-half  inches  and 
ending  in  a  trumpet-shaped  expansion.  It  has  various  diame- 
ters, is  of  a  cord  like  shape  near  the  uterine  end  and  extends 
outward  toward  its  fimbriated  end.  At  times  it  is  very  tortu- 
ous. Just  behind  and  below,  covered  like  a  dome  by  the  tube, 
is  the  ovary. 

The  ovary  is  an  elongated  organ,  situated  to  the  side  and 
behind  the  uterus,  fastened  to  what  is  known  as  the  broad 
ligament;  its  longest  diameter  is  one  and  one-half  inch,  its 
greatest  breadth  is  three-quarters  of  an  inch,  and  its  thickness 
is  one-half  inch.  The  ovaries  are  the  most  important  organs 
in  the  female  generative  system.  It  is  here  that  the  egg  ripens, 
which  is  destined  to  become  the  new  individual.  As  the  ovary 
casts  oil'  the  ripe  egg  it  finds  its  way  into  the  Fallopian  tube, 
where  it  is  carried  along  until  it  becomes  fructified  and  finds 
its  lodgment  in  the  cavity  of  the  bodj^  of  the  uterus. 

When  we  follow  up  the  urethral  orifice  we  find  that  it 
enters  a  canal  about  one  and  one-half  inches  long.    It  is  di- 


rec  ted  upward  and  backward,  opening  into  the  bladder  above. 
This  canal  is  lined  with  mucous  membrane  and  is  somewhat 
dilatable. 

The  bladder  is  the  receptacle  for  urine  as  it  is  excreated 
from  the  kidneys.  When  it  is  fu,lly  distended  its  lateral 
diameter  is  greater  than  its  sagital  diameter.  It  is  a  muscular 
organ  and  lined  with  a  mucous  membrane.  It  is  very  dila- 
table, and  under  normal  conditions  will  easily  hold  one-half 
to  one  pint  of  urine,  and  when  it  is  abnormally  distended  may 
contain  two  quarts  or  more. 

The  rectum,  which  is  the  lower  portion  of  the  intestinal 
tract  and  ends  in  the  anus  below,  is  a  muscu,lar  organ  and  is 
lined  by  mucous  membrane.  It  is  situated  in  the  hollow  of 
the  sacrum,  behind  the  uterus.  As  the  patient  stands  upright 
the  direction  is  at  first  straight  upward,  then  upward  and 
backward  and  to  the  left.  Nature  has  intended  this  as  a  re- 
ceptacle for  the  fecal  discharges  until  such  time  when  at  the 
convenience  of  the  individual  it  can  be  expelled.  Nature 
guards  this  canal  by  a  circular  voluntary  muscle  at  its  lowest 
end.  This  is  a  wise  provision,  as  it  enables  the  individual  to 
retain  the  bowel  contents. 

I  cannot  impress  upon  you  too  much  the  importance  of 
knowing  the  relative  location  and  direction  of  these  various 
canals  and  organs  which  I  have  described  to  you. 

During  my  lectures  I  will  have  occasion  to  return  again 
and  again  to  this  important  subject. 


LECTURE  11. 
THE  USE  OF  THE  CATHETER. 

The  vesical  catheter  is  an  instrument  used  for  the  purpose 
of  emptying  the  urinary  bladder  when,  for  one  reason  or  an- 
other, the  patient  is  unable  to  void  her  urine  or  when  we  wish 
to  obtain  a  specimen  free  from  contamination  for  an  exami- 
nation. 

There  are  two  kinds  of  catheters,  for  the  most  part,  used  in 
the  female.  The  short  glass  catheter  with  a  slightly  turned  up 
anterior  portion  and  openings  on  one  or  both  sides,  and  the 
soft  rubber  catheter.  The  latter  should  be  used  only  excep- 
tionally, and  in  such  cases  where  the  neck  of  the  bladder  has 
been  drawn  up  above  the  pubis. 

The  glass  catheter  is  the  ideal  instrument  for  all  ordinary 
purposes.  It  is  easily  cleansed;  boiling  water  and  chemicals 
do  not  affect  it.  The  eye  can  detect  any  impurities  on  its  inner 
surface.    In  the  use  of  the  catheter  it  is  important  not  to  have 


9 

either  too  large  or  too  small  an  instrument.  A  number  thir- 
teen of  the  American  scale  will  fit  the  Tast  majority  of  cases. 
It  should  be  aseptically  clean  and  kept  so  during  its  introduc- 
tion. 

The  patient  should  be  protected  from  any  unnecessary  ex- 
posure. The  vulva  only  should  be  in  view,  a  light  blanket  or  a 
sheet  should  be  placed  lengthwise  covering  each  leg  sep- 
arately. The  nurse  should  raise  the  knees  to  avoid  any  strain 
on  the  part  of  the  patient. 

The  greatest  gentleness  is  to  be  exercised  as  the  instru- 
ment is  pushed  along  through  the  urethra  into  the  bladder, 
and  a  lubricator  is  seldom  necessary.  As  the  direction  of  the 
urethra  is  at  first  slightly  backward  and  then  upward,  the 
catheter  should  carefully  follow  this  direction.  The  vestibule 
must  be  thoroughly  cleaned  with  a  little  sterile  cotton  and 
water.  Before  the  catheter  is  introduced  it  is  best  to  separate 
the  labia  minora  with  index  and  middle  finger  of  the  left  hand, 
using  the  right  hand  for  the  manipulations  necessary  for  the 
operation.  After  catheterization  immediately  clean  the  in- 
strument and  sterilize  it  so  that  it  will  be  ready  for  the  next 
introduction.  After  cleansing  it,  it  can  be  kept  in  an  anti- 
septic solution,  a  corrosive  sublimate  solution  for  instance, 
which,  however,  should  be  carefully  washed  off  with  sterile 
water  before  reintroducing  the  instrument. 

When  an  inflammation  of  the  bladder  is  produced  by  the 
catheter  it  is  caused  by  a  septic  germ  carried  into  the  viscus. 
A  dirty  catheter  is,  therefore,  responsible  for  this  condition. 
As  a  clean  catheter  cannot  be  passed  into  the  bladder  except 
by  sight,  the  nurse  should  never  hesitate  to  expose  the  patient 
and  use  such  light  as  is  necessary  to  reach  the  desired  end. 
If  you  will  explain  to  the  patient  why  this  is  done  she  will 
never  object.  It  is  important  that  the  upper  part  of  the  body 
be  somewhat  elevated  to  get  a  free  flow  of  urine.  You  should 
never  attempt  to  catheterize  the  bladder  with  the  foot  of  the 
bed  raised,  as  you  will  be  sure  to  have  air  aspirated  into  the 
organ. 

The  nurse  will  sometimes  be  called  upon  to  wash  out  the 
bladder.  In  doing  this  she  should  carefully  follow  the  direc- 
tions given  by  the  surgeon,  using  the  greatest  gentleness  and 
never  overdistend  the  bladder.  The  liquid  to  be  used  for  ir- 
rigation shou,ld  be  of  the  body  temperature  as  the  viscus  is 
very  sensitive  to  heat  or  cold.  The  position  of  the  patient  may 
be  two-fold;  she  may  be  asked  to  lie  flat  on  her  back  with  her 
knees  raised,  or  she  may  be  placed  in  the  knee-elbow  or  even 
the  knee-chest  position.  In  the  latter  position  the  danger  of 
introducing  air  into  the  bladder  should  be  carefully  guarded 
against. 


10 

By  INCONTINENCE  of  urine  we  refer  to  a  condition  where 
the  patient  is  unable  to  retain  urine  in  the  bladder;  as  a  result 
there  is  a  constant  dribbling. 

There  is  a  condition  of  apparent  incontinence  which  is 
really  a  RETENTION  of  urine.  It  means  that  the  bladder  is  so 
full  that  it  overflows,  and  this  condition  should  always  be 
borne  in  mind  when  we  have  an  incontinence  or  a  frequent 
passage  of  very  small  quantities  of  urine. 

By  SUPPRESSION  of  urine  we  mean  that  condition  where 
the  patient's  kidneys  fail  to  excrete. 

It  is  important  that,  you  should  be  familiar  with  these 
terms  and  their  exact  meaning. 

THE  VAGINAL  DOUCHE. 

In  administering  the  vaginal  douche  we  must  remember 
that  the  direction  of  the  vagina  is  upward  and  backward,  and 
that  the  instrument  or  nozzle  must  follow  this  direction. 

The  instruments  used  for  this  purpose  are  a  table,  a  Kelly 
pad,  or  when  the  douche  is  given  with  the  patient  in  bed,  a 
large  douche  pan  and  a  douche  bag  with  its  proper  fitting 
nozzle.  (Among  the  rubber  douche  bags  the  so-called  King's 
Fountain  Syringe,  with  a  thermometer  attached,  is  the  most 
serviceable.) 

For  hospital  purposes  the  metal  or  granite  irrigators  are 
the  most  serviceable.  They  are  the  only  ones  that  bear 
boiling. 

The  object  of  the  hot  vaginal  douche  is  first  cleansing,  and 
secondly  to  get  a  contracting  action  on  the  blood  vessels.  For 
the  latter  purpose  water  of  a  temperature  from  105  to  120  de- 
grees is  used.  It  may  be  aj)plied  in  the  sitting  or  squatting 
posture,  but  is  of  little  or  no  use  in  this  position  unless  the 
vulva  is  tightly  closed  over  the  nozz,le,  thus  preventing  the 
overflow  of  the  liquid.  The  douche  may  be  used  with  the 
patient  lying  flat  on  her  back;  here  the  table  and  Kelly  pad 
are  of  the  greatest  value.  The  hips  should  always  be  raised 
above  the  plane  of  the  back,  and  a  very  small  pillow  allowed 
for  the  head  on,ly.  When  the  patient  is  in  bed  too  much  care 
cannot  be  exercised  in  this  direction,  as  the  value  of  the  hot 
douche  is  very  much  enhanced  by  the  proper  care  as  to  this 
posture.  At  times  it  is  important  that  the  douche  be  given 
while  the  patient  is  on  her  knees  and  elbows  or  even  on  the 
knees  and  chest.  The  bathtub  is  the  most  favorite  place  for 
such  manipulations,  and  great  care  should  be  taken  to  see 
that  the  thighs  are  PERPENDICULAR.  When  it  is  desired 
that  the  patient  should  do  this  in  her  own  room,  the  knee-elbow 
posture  onlj^  can  be  used,  and  a  narrow  baking  pan  should 
then  be  placed  between  the  knees  to  catch  the  water. 


1 1 

* 

Since  we  know  from  the  anatomy  of  the  vagina  that  this 
canal  is  but  three  inches  long,  it  is  only  necessary  to  introduce 
the  tube  but  a  short  distance.  This  is  especially  the  case  when 
we  have  been  careful  to  pjace  the  patient  in  the  posture  I  have 
just  explained  to  you. 

When  the  douche  is  used  for  cleansing  it  should  consist  of 
soapsuds  in  water  at  about  the  body  temperature,  and  should 
not  consist  of  less  than  two  quarts  (2  liters),  allowing  the 
liquid  to  flow  freely.  This  will  occasion  a  loss  of  from  three 
to  five  degrees  temperature  from  the  time  that  the  fluid  leaves 
the  receptacle  until  it  reaches  the  patient.  Tt  should  be  fol- 
lowed by  clean  water  or  an  antiseptic  solution  as  may  be 
directed. 

The  quantity  of  water  used  in  a  douche  depends  entirely 
on  its  object  and  may  be  from  a  pint  to  several  gallons  (8  liters 
or  more.)  The  time  consumed  is  an  important  factor.  The 
slower  the  flow  of  water  the  greater  wil,l  be  its  value  when  a 
hot  douche  is  ordered.  The  temperature  also  is  of  importance 
as  a  very  hot  douche  will  not  cleanse  the  parts,  but  simply 
produce  a  powerful  contraction  of  the  muscular  coat  and  blood 
vessels  of  the  vagina. 

You  will,  therefore,  when  you  prepare  a  patient  for  exami- 
nation or  operation  not  use  a  very  hot  douche,  but  one  at  a 
temperature  of  from  95  to  100  degrees. 

You  will  often  be  called  upon  to  give  medicated  douches. 
Be  sure  never  to  mix  the  medicine  with  the  water  in  the  irri- 
gator. I  have  again  and  again  seen  nurses  prepare  a  car- 
bolized  douche  by  fiilling  the  irrigator  with  the  water  and  then 
pouring  the  carbolic  acid  into  the  water.  The  first  part  of  the 
douche  is  x>ure  carbolic  acid  and  the  result  is  a  frightfully 
burned  patient  and  a  summarily  discharged  nurse. 


LECTUEE  III. 
RECTAL  INJECTIONS. 

By  a  rectal  injection,  enema,  or  clyster,  we  mean  an  opera- 
tion by  which  fluid  is  carried  through  the  anus  into  the  rectum 
and  colon. 

We  divide  the  enema  into  low  and  high  enemas. 
By  a  low  enema  we  mean  the  introduction  of  fluid  by 
means  of  a  small  nozzle  into  the  lower  part  of  the  rectum. 
By  a  high  enema  we  mean  the  introduction  of  the  fluid  high  up 
into  the  bowel,  either  by  a  long  rubber  tube  called  a  rectal 
catheter  or  by  such  posture  as  will  be  s])()k('n  of  later  on. 


12 

The  original  purpose  of  the  rectal  enema  was  to  cleanse 
the  rectum  of  its  contents  by  either  simpl}'  washing  the  bow(4 
out  with  a  large  quantity  of  water  or  else  the  introduction  of 
such  fluids  as  would  excite  the  expulsion  of  its  contents.  It  is 
important  to  know  that  one  enema  is  rarely  enough  for  a 
thorough  cleansing  of  the  bowel.  A  second  enema  of  a  large 
quantity  of  y»urm  water,  a  quart  or  more  shou,ld  immediately 
follow  the  expulsion  of  the  first.  When  this  is  done  for  the 
purpose  of  preparing  a  i)atient  for  an  examination  or  opera- 
tion the  last  enema  should  be  given  AT  LEAST  THREE 
HOUES  before  the  time  set  for  the  operation,  otherwise  the 
operator  may  be  seriously  annoyed  by  having  the  patient's 
bowels  move  during  the  operation.  The  patient's  life  may  be- 
come endangered  hj  an  infection  of  the  wound  from  these  de- 
jections. Whenever  such  annoyance  occurs  the  nurse  is  to 
blame  in  the  majority  of  cases,  and  is  by  no  means  a  recom- 
mendation as  to  her  ability.  The  temperature  for  an  enema 
should  be  about  100  degrees. 

It  will  be  of  value  to  you  to  know  that  the  rectum  does  not 
bear  antiseptics  well.  Besides  the  irritating  effect  of  the  anti- 
septic there  is  a  chance  for  rapid  absorption  producing  a  fatal 
result. 

A  second  purpose  of  the  rectal  enema  is  for  the  introduc- 
tion of  medicines  into  the  system.  Medicines  are  used  in  this 
way,  when  the  patient  is  unable  to  swallow  or  when  the  stom- 
ach will  not  retain  the  drug,  or  when  for  any  reason  we  wish 
to  give  the  stomach  a  rest. 

The  quantity  injected  for  this  purpose  should  not  exceed 
sixty  C.  C.  (2  ounces),  nor  should  it  be  administered  oftener 
than  once  in  two  hours. 

The  third  purpose  of  the  rectal  enema  is  for  the  introduc- 
tion of  food  into  the  bowel.  Various  mixtures  will  be  advised 
to  you  for  this  purpose. 

Few  patients  will  tolerate  more  than  200  c.  c.  m.  (6  or  vS 
ounces)  once  in  six  hours.  It  should  be  given  very  slow,ly. 
The  time  for  the  introduction  should  be  from  five  to  fifteen 
minutes.  Milk,  peptonized  milk,  eggs,  normal  salt  solution 
and  stimulants  are  most  frequently  given.  Brandies  and 
whiskies  can  be  given  only  in  vpry  small  quantities,  as  they 
soon  irritate  the  rectum.  Once  in  twenty-four  hours  the  bowel 
should  be  flushed  with  a  normal  salt  solution. 

A  fourth  use  for  the  rectal  enema  is  the  introduction  of  fluid 
into  the  circulation  after  hemorrhage  and  shock  following  op 
erations  or  accidents.  For  this  purpose  the  enema  should 
consist  of  what  is  known  as  a  normal  salt  solution.  It  is  made 
up  of  six  parts  of  common  salt  in  one  thousand  parts  of  water, 
(one  dram  to  the  pint  of  sterile  water).   During  the  admin- 


istration  of  the  normal  salt  solution,  the  patient,  lying  on 
her  back,  should  have  her  feet  elevated,  and  too  much  stress 
cannot  be  laid  upon  the  slow  and  steady  stream  vv^hich  is  re- 
quired for  this  manipulation.  The  temperature  shoujd  be 
about  that  of  the  body,  from  05  to  100  degrees. 

The  position  in  which  an  enema  can  be  administered  may 
be  either  the  left  or  the  right  lateral ;  flat  on  the  back  with 
the  knees  raised;  flat  on  the  back  with  the  bed  inclined  to- 
ward the  head;  in  the  knee-elbow  posture,  and  in  the  knee- 
chest  posture.  For  ordinary  purposes  the  left  lateral  position 
is  the  most  convenient.  When  it  is  desired  that  the  fluid 
should  go  high  up  into  the  bowel,  i.  e.,  the  colon,  the  right 
lateral  position  has  in  my  experience  given  me  the  best  re- 
sults, as  I  have  been  able  to  trace  the  fluid  into  the  transverse 
and  descending  colon.  Of  course,  when  the  patient  is  able  to 
go  on  her  knees  and  chest,  that  will  be  the  most  favorable  po- 
sition for  a.  high  enema. 

Sometimes  it  is  desirable  to  simply  flush  the  bowel  and 
then  the  patient  is  allowed  to  remain  flat  on  her  back  with 
her  knees  raised.  After  properly  protecting  the  bed  with  a 
rubber  sheet,  etc.,  the  patient  is  placed  direct.ly  on  a  bed  pan. 
Protect  the  patient's  back  by  placing  a  folded  towel  upon  that 
portion  of  the  bed  pan  upon  which  the  patient  rests.  You 
should  also  see  that  the  bed  pan  is  not  cold.  A  large  rubber 
rectal  catheter  is  then  introduced,  and  the  patient  is  directed 
not  to  make  any  attempt  to  retain  the  fluid  as  it  passes  into  the 
organ. 

This  would  lead  us  to  speak  of  the  great  difficulty  often 
experienced  in  moving  the  bowels  of  a  woman  confined  to  her 
bed.  This  difficulty  is  experienced  from  the  fact  that  she  must 
have  her  bowels  moved  while  in  an  unaccustomed  position 
for  that  function,  also  that  she  likely  has  been  placed  upon  a 
liquid  or  light  diet,  and  from  the  lack  of  ajl  muscular  ex- 
ercise. 

A  few  things  are  to  be  noticed,  especially  in  regard  to  the 
movements.  While  a  patient  may  have  an  apparent  diarrhoea 
she  may  be  suffering  from  a  large  collection  of  fecal  matter 
in  the  rectum,  usually  called  an  impaction  of  feces.  This  can 
only  occur  when  the  nurse  has  not  observed  the  quantity  of  the 
alvine  discharges.  It  is  remedied  by  large  injections  of  sweet 
oil,  from  200  C.  C.  M.  to  500  C.  C.  M.  (Six  ounces  to  one  pint), 
followed  by  a  copious  enema  of  warm  soapsuds.  If  this  does 
not  soften  and  bring  away  the  masses  they  must  be  broken 
up  with  the  finger,  and  by  repeated  warm  water  injections  the 
broken  up  masses  should  be  brought  away. 


H 
GENERAL  OBSERVATIONS. 

It  is  important  for  the  nurse  that  she  should  make  some 
general  observations  about  the  person  of  her  patient.  She 
should  report  to  the  doctor  any  soreness,  swelling,  pro- 
tuberance, discharges,  cough,  expectoration  and  the  character 
and  quantity  of  urine  excreted;  also  shape,  form,  consistency 
and  odor  of  the  recta]  discharges. 

In  the  gynecological  cases  observe  especially  anything 
that  may  appear  wrong  about  the  private  parts  of  the  patient. 
The  character,  odor  and  quantity  of  discharge  from  the  vagina. 
Report  to  the  doctor  any  peculiar  and  bad  habits  vou  may 
notice  about  your  patient.  Of  the  latter  it  willl  be  wise  not  to 
speak  of  to  the  patient  herself.  Of  the  character  of  the 
vaginal  discharge  you  should  note  especially  whether  it  is 
bloody  or  foul  smelling;  if  it  is  bloody,  whether  it  is  bright 
red  or  dirty  brown,  whether  it  is  thin  or  thick,  or  clotted. 
At  times  there  wijl  be  a  j'ellow-white  or  glary  discharge  of 
ropy,  thick  or  thin  fluid. 


MENSTRUATION. 

Among  the  vaginal  discharges  which  occur  normally  we 
bave  the  discharge  of  menstruation.  By  menstruation  is  un- 
derstood a  flow  of  blood  from  the  uterus  recurring  at  certain 
intervals  and  connected  with  the  ripening  or  discharge  of 
an  ovule  from  the  ovary.  While  this  discharge  of  the  ovule 
from  the  ovary  may  not  always  happen  at  the  exact  time  of 
menstruation  it  usually  occurs  near  it.  At  all  events  the 
ovary  is  the  exciting  cause  of  menstruatioUj^  It  is  called  a 
normal  and  a  physiological  menstruation  when  a  woman  be- 
tween the  age  of  puberty,  usually  from  twelve  to  fourteen 
years,  until  the  time  of  the  climacteric,  from  forty-five  to  fifty 
years  of  age,  has  a  periodical  flow  of  blood.  Normally  this 
occurs  once  in  twenty-eight  days.  It  usually  lasts  from  four 
to  six  days,  and  it  is  accompanied  by  some  slight  general 
malaise  and  uneasiness.  The  quantit}^  of  the  bloody  discharge 
is  not  always  easy  to  ascertain.  The  usual  way  is  to  inquire 
as  to  the  number  of  nai3kins  a  patient  soils.  Two  napkins  a 
day  should  be  considered  about  normal.  The  habits  of  the 
patient  during  her  former  ,life  in  this  regard  should  be  taken 
into  consideration.  For  what  might  be  a  normal  quantity  for 
one  woman  v/ould  prove  an  excessive  quantity  for  another  one. 
That  loss  which  proves  a  source  of  exhaustion  to  any  woman 
is  certainly  a  pathological  quantity. 


15 

The  largest  amount  of  flow  usually  occurs  on  the  first  and 
second  days.  The  character  of  the  flow  is  commonly  of  a 
dirty  reddish-brown  character,  and  is  often  preceded  or  fol- 
lowed by  a  slight  glairy  discharge. 

Menstruation  becomes  pathological  when  the  period  of 
flow  is  shorter  or  longer  than  twenty-eight  days;  when  the 
time  of  the  flow  is  but  one  or  two  days  or  more  than  a  week, 
when  the  quantity  is  excessively  large  or  very  small,  and  when 
the  character  is  bright  red,  clotted  or  foul-smelling.  Men- 
struation also  becomes  pathological  when  accompanied  by 
excessive  pain. 

Terms  used  by  the  laity  for  this  flow  is  the  monthly  sick- 
ness, the  monthly  period,  the  regular  flow,  the  unwell  period, 
etc. 

Always  report  the  appearance,  the  expectancj^  or  the 
cessation  of  menstruation  as  it  is  often  necessary  to  discon- 
tinue medicines,  local  applications,  douches,  etc.,  and  may 
call  for  other  suggestions  as  to  treatment. 


LECTURE  IV. 
PREGNANCY  AND  ABORTION. 

It  is  wise  both  for  the  doctor  and  the  nurse  always  to  sus- 
pect pregnancy.  Great  worry,  humiliation  and  chagrin  may 
be  spared  to  them,  and  great  danger  and  sorrow  to  the  pa- 
tient. 

Our  attention  should  be  directed  to  a  possible  pregnancy 
as  soon  as  the  patient  has  gone  over  the  usual  time  of  men- 
struation. The  cessation  of  menstruation  is  then  usually  one 
of  the  first  symptoms  of  pregnancy.  This  is  the  more  so  if  the 
woman  has  heretofore  been  regular.  This  sign  is  really  of 
great  practical  value.  Of  course,  there  are  circumstances 
under  which  suppression  occurs,  due  to  morbid  conditions  or 
a  pregnancy  may  occur  in  the  absence  of  menstruation. 
Women  do  become  pregnant  during  an  amenorrhea,  and  this 
should  be  remembered.  The  next  symptom,  which  is  most 
frequent,  is  the  nausea  and  sickness  upon  rising  after  the 
night's  sleep.  It  is  usually  termed  the  morning  sickness. 
Among  the  objective  signs  the  earliest  is  a  darkening  and 
widening  of  the  areolar  around  the  nipple. 

The  symptoms  just  enumerated  refer  to  the  signs  of  preg- 
nancy of  the  early  months  only.  The  signs  of  pregnancy  of 
the  ,latter  months  has  been  taught  you  by  the  obstetrician  of 
the  institution. 


i6 

When  after  such  a  cessation  of  menstruation  and  morning 
sickness  a  patient  has  abdominal  pains,  bloody  discharge  or  a 
hemorrhage,  we  may  expect  an  abortion. 

By  abortion  we  mean  an  expulsion  of  the  ovum  before  the 
fourth  month,  i.  e.,  at  a  time  when  the  chorion  has  not  yet 
changed  into  the  placenta.  Such  a  patient  should  be  put  to 
bed  immediately  and  appropriate  medical  advice  sought. 

The  dangers  of  abortion  are:  First,  hemorrhage,  which 
may  be  very  excessive,  but  rarely  dangerous  to  life.  Second, 
sepsis,  as  shown  by  chill,  fever,  foul  discharge  and  general 
illness  of  the  patient.  This  is  a  dangerous  condition  and  early 
surgical  treatment  is  advisab.le.  The  nurse  may  be  called  upon 
in  the  absence  of  the  medical  adviser  to  treat  a  case  of 
abortion.  Her  assistance  should  be  of  the  most  temporary 
kind,  and  she  should  never  take  upon  herself  the  serious  re- 
sponsibility which  accompanies  such  an  accident. 

When  the  hemorrhage  is  free  she  should  immediately  raise 
the  foot  of  the  bed,  but  not  less  than  twenty  inches.  She 
should  remove  all  of  the  pillows  and  bolsters  from  under  the 
patient's  head  and  shoulders,  iit  such  times  the  patient 
should  not  have  hot  drinks  as  they  tend  to  re.lax  the  muscular 
sphincters.  When  the  patient  becomes  faint  she  may  be  given 
Hoffman's  Anodyne  in  small  doses  to  be  repeated  every  fifteen 
or  thirty  minutes.  Plenty  of  fresh  air  and  very  little  bed 
clothing.  In  extreme  cases,  and  when  no  medical  assistance 
can  be  summoned,  it  will  be  proper  to  tampon  the  vagina.  For 
this  purpose  she  should  be  as  clean  as  circumstances  will 
permit.  In  the  absence  of  sterile  gauze,  cotton  or  an  antisep- 
tic gauze,  she  may  use  clean,  recently  ironed  handkerchiefs 
wrung  out  of  boiling  water.  In  place  of  a  speculum  a  metal 
shoe  horn  may  be  of  value. 

The  treatment  by  the  nurse  for  sepsis  should  rather  be 
preventative  than  otherwise  She  should  keep  the  vulva  and 
its  surroundings  clean  and  dry.  The  discharge  should  be 
caught  up  in  sterile  or  antiseptic  gauze.  If  the  gauze  is  sterile 
it  should  be  changed  more  frequently  than  an  antiseptic 
gauze. 

Great  care  should  be  exercised  during  defecation,  so  that 
no  fecal  discharge  will  enter  the  genital  tract.  When  sepsis 
has  once  set  in  the  nurse  should  not  fol.low  any  routine  except 
the  greatest  care  and  cleanliness,  but  should  most  strictly 
obey  the  attending  physician's  orders. 


17 

PREPAEATION  OF  THE   PATIENT  FOR   GYNECO- 
LOGICAL EXAMINATIONS  AND  VAGINAL 
APPLICATIONS. 

The  table  for  gynecological  examinations  should  be  short, 
not  over  75  centimeters  (30  inches)  in  height,  60  centimeters 
(24  inches)  in  width,  and  100  centimeters  (40  inches)  in  length. 
A  wider  or  a  longer  table  will  prove  a  great  inconvenience;  a 
chair  should  be  placed  at  the  lower  end  of  the  table  not  over 
45  centimeters  (18  inches)  in  height,  so  that  the  patient's  feet 
will  rest  on  the  chair  while  she  is  lying  flat  on  her  back. 

The  nurse  should  be  prepared  with  the  necessary  basin, 
soap  and  towel  for  the  doctor's  use.  If  a  lubricant  is  de- 
manded it  should  be  sterile  vaseline  or  a  20  per  cent,  borated 
vaseline.  The  latter  can  never  be  used  again  when  the  soiled 
finger  has  touched  it.  The  table  should  be  of  sufficient 
strength  to  hold  the  patient  and  should  be  covered  with  a 
clean  blanket  and  sheet,  which  is  best  pinned  down  so  as  to 
remain  in  place.  A  small  pillow  for  the  head  finishes  the 
preparation  of  the  table. 

The  patient  is  prepared  by  a  thorough  enema  unless  the 
bowels  have  moved  spontaneously  shortly  before.  The  nurse 
should  inspect  the  vulva  before  the  arrival  of  the  doctor  and 
see  that  it  is  c,lean.  Want  of  cleanliness  reflects  upon  the 
ability  of  the  nurse  to  discharge  her  duties  in  a  proper 
manner. 

All  of  the  clothing  about  the  waist,  abdomen  and  breast 
should  be  loose.  This  is  an  important  consideration  in  a  well- 
conducted  examination. 

The  patient  is  examined  in  the  following  positions: 

First — Dorsal. 

Second — Left  lateral,  position  of  Sim's. 

Third — Knee-elbow  position. 

Fourth — Knee-chest  position. 

By  the  dorsal  position  we  mean  that  the  patient  lies  flat 
on  her  back,  with  the  head  and  shoulder  s,lightly  elevated;  the 
lower  limbs  are  extended  or  flexed,  as  the  operator  may  desire. 
This  is  the  posture  used  for  an  abdominal  examination.  When 
the  examination  becomes  vaginal  the  knees  should  be  flexed 
and  raised  so  that  the  patient's  feet  will  rest  on  each  side  of 
the  table.  The  knees  are  then  widely  separated  so  as  to  expose 
to  view  the  external  genitals.  That  this  may  be  done  prop- 
erly it  will  have  been  necessary  to  raise  the  ijatient's  skirts 
behind  her  before  she  sits  down  upon  the  table.  The  patient 
should  also  have  been  covered  with  a  sheet  under  which  the 
front  part  of  the  clothing  has  been  pushed  up  beyond  the  hips. 


When  the  examination  is  to  be  abdominal  the  clothing  should 
be  pushed  well  up  under  the  arms.  With  nervous  women  it  will 
often  be  necessary  for  the  nurse  to  keep  the  knees  separated 
hx  holding  them  apart.  This  should  be  done  with  gentleness 
and  firmness,  which  will  soon  tire  out  the  adductor  muscles  of 
the  thighs. 

Now  and  then  you  will  be  asked  to  get  the  patient  in  such 
a  position  that  the  pelvis  and  thighs  are  raised  above  the  chest 
and  head;  to  do  this  it  is  necessary  to  flex  the  thighs  upon  the 
abdomen,  which  will  ejevate  the  hips  and  sacrum.  This  po- 
sition is  often  called  the  lithothomy  posture  by  surgeons 
generally,  and  is  a  modified  dorsal  position. 

For  an  examination  in  the  left  semi-prone  position  of  Sim's 
it  is  important  that  you  should  follow  the  directions  which 
I  now  give  you,  otherwise  you  will  fail  in  your  endeavors.  The 
patient's  skirts  having  been  raised  behind  her,  she  is  asked  to 
sit  down  at  the  right-hand  lower  edge  of  the  table  upon  the 
left  half  of  the  buttock.  She  is  then  told  to  lie  upon  her  left 
side  and  as  she  goes  down  her  left  arm  is  drawn  behind  her 
while  the  right  shoulder  is  pushed  toward  the  surface  of  the 
table.  The  face  is  brought  over  to  the  left  side  of  the  table 
and  the  right  arm  is  allowed  to  hang  over  the  left  side  of  the 
table.  Both  knees  are  placed  upon  the  table  in  such  a  way 
that  the  thigh  of  the  left  (lower)  limb  extends  at  right  angles 
from  the  body,  while  the  right  knee  is  placed  above  the  left 
one.  It  should  not  be  forgotten  that  to  do  this  properly  there 
should  be  no  pillow  under  the  patient's  face,  but  she  should 
lie  upon  a  perfectly  fiat  table.  If  it  is  found  that  the  upper 
portion  of  her  trunk  has  not  rotated  sufQciently  forward,  a 
slight  pressure  upon  the  right  shoulder  in  that  direction  wi,ll 
accomplish  the  desired  end.  The  nurse  then  takes  a  position 
at  the  lower  right-hand  end  of  the  table,  pushing  all  the 
clothing  up  above  the  hips  under  the  sheet,  which  she  has 
already  spread  over  the  patient.  This  sheet  is  raised  suf- 
ficiently to  uncover  the  left  buttocks  and  the  genitals,  while  a 
fold  of  it  is  tucked  in  between  the  thighs.  The  nurse  is  now 
prepared  for  any  assistance  she  may  be  asked  to  give. 

The  Sim's  speculum  must  be  held  in  position  by  the  nurse. 
To  do  this  she  must  stand  to  the  right  and  back  of  the  patient, 
facing  the  surgeon.  It  is  also  important  that  the  nurse  stands 
firmly  and  quietly  on  both  feet.  If  she  so  desires  she  may  rest 
her  right  arm  on  her  hip  while  she  holds  the  speculum;  this 
leaves  the  left  hand  free  so  that  she  may  raise  the  right 
buttock  of  the  patient  or  separate  the  labia  if  so  desired. 

The  knee-elbow  posture  is  accomplished  in  the  following 
way:  The  patient  is  asked  to  stand  upon  the  chair  at  the 
lower  end  of  the  table,  facing  the  table.    The  skirts  are  raised 


in  front  of  her  and  she  is  then  directed  to  kneel  upon  the 
table.  She  now  bends  her  body  down  forward  and  rests  her 
trunk  upon  her  elbows.  It  is  very  important  that  the  thighs 
should  be  perfectly  perpendicular  as  this  raises  the  hips  to  the 
greatest  possible  height  in  relation  to  the  rest  of  the  body. 
The  patient  is  now  covered  with  a  sheet  and  her  clothes 
raised  over  her  back  under  it.  The  knees  are  then  separated 
for  six  or  eight  inches  and  the  patient  is  j"^ady  for  ex- 
amination. 

When  the  knee-chest  position  is  desired  you  will  simply 
have  to  get  the  patient  from  the  knee-elbow  posture  into 
the  former  by  asking  her  to  rest  her  face  and  as  much  as 
possible  of  her  chest  upon  the  table  with  the  arms  lying 
above  the  head,  always  remembering  that  the  thighs  should 
remain  PERFECTLY  PEEPENDICULAR. 

The  instruments  to  be  used  during  the  examination  should 
be  placed  upon  a  clean  towej  or  in  a  basin  of  warm  water,  to 
the  right  hand  of  the  operator.  It  is  well  to  have  some  clean 
cotton  ready  to  be  used  as  wipes  and  a  basin  into  which 
soiled  instruments,  cotton  and  dressings  may  be  thrown. 

When  you  are  asked  to  prepare  cotton  or  oakum  tampons, 
make  them  of  medium  size  with  a  clean  string  tied  around 
the  middle  so  that  the  tampon  will  take  the  form  of  a  dumb- 
bell. The  oakum  tampon  should  always  be  covered  with  a 
thin  layer  of  cotton. 

Always  remind  your  patient  that  the  tampon  must  be 
removed  and  tell  her  when.  At  times  it  will  be  necessary 
that  the  patient  be  supplied  with  a  vulva  pad. 

You  will  sometimes  be  called  upon  to  clean  pessaries 
that  have  remained  in  the  vagina  for  a  long  time.  They 
should  be  brushed  first  with  Sapolio  and  warm  water.  If 
there  is  any  calcareous  concretions  on  the  pessary  which  is 
so  common  with  those  that  have  remained  in  the  vagina 
for  a  long  time,  it  should  be  removed  by  washing  or  dipping 
the  instrument  into  a  dilute  solution  of  muriatic  acid,  and 
washed  off  with  plain  water. 

Vaginal  suppositories  are  frequently  ordered.  They  come 
in  various  shapes  and  sizes.  When  they  are  made  of  butter  of 
cocoa  they  need  no  lubricant,  otherwise  a  little  moist  soap  will 
answer  very  we,ll.  The  nurse  should  proceed  in  the  following 
way  in  their  introduction:  Standing  on  the  right  side  of  the 
patient,  with  the  patient  on  her  back,  she  separates  the  knees 
widely  and  with  the  left  hand  parts  the  labia  majora,  while 
with  the  right  hand  she  introduces  the  suppository  into 
the  vaginal  orifice,  pushing  it  along  with  the  finger  until 
it  is  arrested  in  the  posterior  cul-de-sac  of  the  vagina.  The 
Ijatient  is  then  directed  to  remain  in  the  dorsal  position 
f(jr  an  hour  or  more. 


20 

When  you  are  called  upon  to  make  a  vaginal  application 
it  will  be  done  most  readily  by  the  instrument  known  as 
Thomas's  Cupping  Cup.  The  piston  of  this  instrument  is 
withdrawn  half-way,  a  tampon  with  a  string  attached  pushed 
into  it  until  it  has  been  arrested.  This  is  then  filled  with  the 
lit|uid  prescribed  for  the  application  and  the  piston  drawn 
down  the  other  half  of  the  instrument.  The  result  of  this  is 
that  the  liquid  is  drawn  into  the  cotton.  The  instrument  is 
now  introduced  into  the  vagina  as  high  as  it  can  be  pushed 
and  the  cotton  and  liquid  forced  out.  The  string,  which  has 
been  allowed  to  hang  down  from  the  instrument,  will  now 
hang  from  the  vagina. 


LECTURE  V. 
SURGICAL   CLEANLINESS. 

You  have  heard  me  speak  in  my  past  lectures  about  clean- 
liness, about  sterile  instruments  and  sterile  dressings.  It 
will  be  my  duty  to  tell  you  what  we  mean  by  surgical  clean- 
liness in  relation  to  gynecological  nursing. 

By  surgical  cleanliness  we  mean  that  everything  that  may 
come  in  contact  with  a  wound  or  its  surrounding  should  be 
free  from  dirt  and  living  organism,  and  a  well-trained  and 
conscientious  nurse  will  consider  it  a  disgrace  to  make  a  break 
in  those  details  which  insure  such  cleanliness.  It  will  pre- 
vent serious  illness  to  the  patient  and  its  importance  in 
operative  gj^necological  work  cannot  be  overestimated.  When 
a  patient  gets  sick  after  an  operation,  with  fever  and  other 
symptoms  of  blood  poisoning,  we  may  truly  ask  ourselves : 
Who  was  dirty? 

It  is  not  uncommon,  I  am  Borrj  to  say,  to  meet  unclean 
doctors,  and  it  will  be  your  duty  to  prepare  things  in  such 
a  way  that  the  least  amount  of  harm  will  result  from  his 
work,  but  it  wi,ll  be  the  duty  of  the  clean  doctor  to  ask  for 
a  clean  nurse  when  an  incompetent  one  presents  herself. 

The  part  of  the  body  which  the  gynecologist  is  asked  to 
treat  is  the  most  difficult  to  keep  clean.  Its  closeness  to  the 
end  of  the  alimentary  canal  with  its  discharges,  the  moisture 
and  discharges  from  the  genito-urinary  tract  and  the  warmth 
of  that  part  of  the  body  are  all  factors  which  favor  decompo- 
sition and  growth  of  living  organisms.  The  greatest  care 
should  be  exercised  in  keeping  all  of  these  discharges  from 
recent  wounds.  They  are  all  poisons  in  a  greater  or  less  de- 
gree. Your  hands  should  be  cjean  from  such  poisons  when 
you  are  called  upon  to  perform  manipulations  in  other  cases. 


21 

We  eau  prevent  wound  poisoning  by  first  avoiding  to  carry 
the  poison  to  the  patient. 

Second,  by  avoiding  to  give  wound  poison  a  chance  to 
grow  and  multiply,  and 

Third,  by  carrying  poison  from  one  patient  to  another. 

The  first  is  done  by  allowing  only  clean  things  to  come 
in  contact  with  the  patient. 

The  second  is  accomplished  by  promptly  remoying  all 
discharges  from  the  wound  and  its  neighborhood,  thus  taking 
away  the  medium  in  which  the  germ  will  grow. 

The  last  is  reached  by  the  nurse  who  wil,l  consider  it  her 
duty  to  abstain  from  handling  a  clean  patient  when  she  has 
been  in  attendance  upon  one  suffering  with  a  suppurating  or 
infectious  diseases.  Such  poisoning  is  called  sepsis  and  means 
the  result  of  putrefactive  changes  in  the  body. 

All  wound  poisoning  is  produced  by  germs. 

We  often  hear  the  term  SEPTIC.  This  means  a  thing  that 
will  cause  sepsis;  for  this  reason  a  septic  body  is  a  substance 
that  under  favorable  circumstances  promotes  and  produces 
putrefaction.  Surgical  sepsis  arises  from  the  invasion  of  a 
wound  by  pathogenic  or  disease  producing  micro-organisms 
which  find  in  the  tissues  suitable  conditions  for  their  de- 
velopment and  growth. 

ASEPSIS  means  freedom  from  germs.  An  antiseptic  is  a 
body  not  only  free  from  germs  but  one  that  will  kill  them.  The 
term  disinfectants  is  applied  to  agents  used  for  destroying 
septic  material.  You  will  do  well  not  to  use  this  term  in  your 
examinations,  but  rather  express  yourself  in  fitting  language 
how  such  an  end  is  reached. 

There  are  certain  things  that  are  especially  dangerous 
as  sources  o-f  infection,  because  they  form  good  media  for 
germ  growth,  like  blood,  mucus,  urine,  fecal  discharges,  etc. 
Thus  also  are  all  of  the  discharges  from  wounds;  the  dis- 
charges from  the  womb  after  child  birth  and  miscarriages. 
A  dangerous  source  of  infection  is  found  in  scarjet  fever, 
erysipelas,  diphtheria  and  the  poisons  of  dead  bodies.  For  her 
own  sake  the  nurse  should  be  careful  never  to  touch  septic 
matter  with  sore  fingers.  It  is  best  not  to  touch  it  at  all, 
but  use  instruments  for  all  manipulations.  A  nurse  whose 
ward  work  brings  her  into  direct  contact  with  abscesses, 
sloughing  carcinomata,  suppurating  wounds,  etc.,  must  be 
debarred  from   helping  at   operations   or  making  dressings 

for  c1g9.i1   C3.SGS 

THE  BEST  NURSE  IS  THE  ASEPTIC  NURSE.  I  look 
with  great  suspicion  upon  the  antiseptic  nurse  and  doctor. 
They  succeed  more  frequently  in  killing  their  patient  with  the 
antiseptics  than  in  killing  the  germs. 


22 

Personal  ejeanliness  must  be  observed  by  frequent  bath- 
ing, elianges  of  underclotliing  and  linen.  A  nurse  wlio  is  dirty 
in  her  general  habits  is  unfit  to  be  a  nurse  at  all.  While  this 
is  especially  so  in  surgical  work,  she  is  a  dangerous  nurse 
at  all  times.  The  obligation  to  keep  clean  begins  long  before 
entering  the  operating  room  for  the  purpose  of  ''WASHING 
UP."  It  is  a  duty  devolving  upon  nurses  to  avoid  direct 
contact  with  septic  material  at  all  times.  It  is  possible  to  do 
so,  and  to  scrub  the  hands  thoroughly  after  any  such  con- 
tact. The  nurse  should  educate  herself  to  a  feeling  of  aver- 
sion to  touching  anything  unclean.  There  is  nothing  heroic 
in  puddling  in  dirt. 

All  instruments  should  be  made  aseptic  by  the  use  of 
Sapolio,  soap  and  brush,  and  then  boiling  them.  Boiling  in  a 
1  per  cent  soda  solution  also  has  the  great  advantage  of  pre- 
venting rust.  This  you  will  find  to  be  much  better  than 
using  strong  antiseptic  solutions,  for  if  the  instruments  have 
any  grease  upon  them  the  antiseptic  wi,ll  not  penetrate. 
Besides  they  spoil  the  instruments. 

All  of  the  trays  and  basins  are  safe  only  when  they  have 
been  boiled.  All  glass  instruments,  such  as  catheters  and 
tubes,  douche  nozzles,  etc.,  should  be  sterilized  by  boiling, 
and  kept  so,  ready  for  use  in  a  saturated  solution  of  boric  acid 
or  a  corrosive  sublimate  solution  1-2000.  When  a  strong  anti- 
septic, such  as  corrosive  sublimate  is  used,  the  instrument 
should  always  be  washed  off  with  sterile  water  before  touch- 
ing the  patient. 

Aseptic  vaseline  should  be  used  as  a  lubricant  for  all 
instruments.  It  is  prepared  by  heating  vaseline  in  the  oven 
for  one-half  hour.  Vaseline  can  be  rendered  aseptic  in  a  very 
few  minutes  in  a  spoon  held  over  a  gas  flame  until  it  begins, 
to  boil. 


LECTURE  VI. 


GENERAL  REMARKS  ON  THE  PREPARATION  OF  PA- 
TIENTS FOR  ABDOMINAL  AND  GYNE- 
COLOGICAL OPERATIONS. 

For  all  of  these  operations  which  come  under  the  head 
of  abdominal  and  gynecological  operations  we  have  gradually 
learned  that  the  patient  does  better  and  has  an  easier  conva- 
lescence, if  she  undergoes  such  preparatory  treatment  as  will 
cleanse  the  skin,  will  empty  the  bowels  and  keep  them  so. 
For  that  reason  the  patient  should  have  a  hot  soap  bath 


and  a  good  rubbing  with  a  coarse  towel.  A  laxative  and 
a  rectal  injection  are  necessary  to  carry  away  the  fecal  dis- 
charges which  you  know  so  often  accumu,late  in  the  bowels 
of  some  people.  In  order  that  the  bowels  may  remain  empty 
the  diet  should  be  of  such  a  character  as  will  leave  little 
residue  in  the  alimentary  tract.  Such  a  diet  should  consist 
of  milk,  broths  and  gruels.  Especially  is  this  the  case  on  the 
day  previous  to  the  operation.  We  should  especially  avoid 
such  food  as  wil,l  produce  gas  in  the  intestines.  The  skin 
about  the  location  of  the  operation  should  be  thoroughly 
cleansed  by  lathering  with  soap  and  shaving. 

While  you  are  in  the  hospital,  at  least,  never  forget  to 
send  to  the  house  surgeon  a  specimen  of  urine  which  should 
have  been  drawn  with  a  catheter.  When  you  send  a  specimen 
of  urine  to  the  doctor's  office  it  is  wise  to  send  it  in  such  a 
way  that  decomposition  can  take  place  only  very  slowly. 
In  fact,  with  great  care  one  can  draw  a  specimen  of  urine 
which  will  keep  very  we,ll  for  several  days.  The  method  by 
which  this  is  done  is  the  following:  A  small  rubber  tube  is 
fastened  to  the  end  of  a  catheter  and  this,  with  the  bottle 
into  which  the  urine  is  to  be  drawn  and  the  cork  with  which 
to  close  the  bottle,  are  all  boiled  for  ten  minutes.  When 
the  urine  is  drawn  (of  course,  with  the  precautions  already 
spoken  of),  the  rubber  tube  is  allowed  to  hang  into  the  bottle 
and  as  soon  as  the  bottle  is  quite  ful,l  it  is  tightly  corked  with 
the  sterile  cork.  The  whole  neck  of  the  bottle  is  then  cov- 
ered with  sterile  cotton  and  gauze. 

The  patient  is  prepared  by  thoroughly  shaving  and  scrub- 
bing the  location  to  be  operated  upon.  A  bi-chloride  towel  is 
then  placed  over  the  parts.  As  the  patient  goes  upon  the  oper- 
ating table  she  should  have  her  trunk  and  lower  limbs  cov- 
ered with  flannels,  artificial  teeth  removed  and  all  tight 
bands  loosened.  The  patient  should  always  be  catheterized 
before  an  abdominaloperation,  i.  e.,  after  she  is  well  under 
the  anesthetic. 

The  nurse  should  be  clean  herself.  She  should  refrain 
from  nursing  a  surgical  case  if  she  has  lately  been  in  at- 
tendance on  a  septic  case.  A  hot  bath  and  a  change  of 
washable  clothing  are  an  important  requirement  for  every 
operation. 

When  the  operation  is  over  the  patient  shou,ld  be  speedily 
made  dry  and  placed  in  a  warm  bed. 

Nurses  are  often  at  a  loss  to  know  how  to  prepare  for  a 
change  of  dressing  in  a  private  house.  They  have  been  ac- 
customed to  receive  everything  sterile  and  now  they  are  left 
without  it.  They  will  succeed  fairly  well  if  they  follow  these 
directions:     Cotton  pledgets  of  the  size  of  hickory  nuts  are 


24 

placed  in  a  clean  fruit  jar  until  the  jar  is  full.  The  nurse  then 
supplies  the  jar  with  a  rubber  washer  and  cap.  A  similar 
jar  is  then  filled  with  rolls  of  absorbent  cotton,  which  when 
unrolled  will  be  six  by  eight  inches  in  size.  These  jars, 
tightlv  closed,  are  then  wrapped  in  a  towel  so  that  they  will 
get  wet  all  over.  They  are  now  boiled  for  three  hours.  Gauze 
pledgets  and  dressings  are  steri.lized  in  the  same  way.  Sterile 
towels  are  made  in  this  way,  or  else  in  the  following:  A 
clean  sheet  is  spread  over  an  ironing  board  and  sprinkled 
thoroughly  with  clean  water  and  ironed  with  a  very  hot 
smoothing  iron.  A  clean  towel  is  then  spread  upon  this  sheet 
and  sprinkled  with  clean  water.  She  now  irons  this  towel 
until  it  is  thoroughly  dry  with  the  \erj  hot  iron;  this  is  then 
laid  aside  on  the  sheet  just  spoken  of,  and  another  towel  is 
then  ironed  and  fo.lded.  Each  towel  is  thus  thoroughly  ironed 
and  nicely  folded  and  placed  on  the  side  of  the  ironing  board 
that  is  covered  with  the  sheet.  In  this  way  she  irons  and 
folds  four  towels,  eventually  wrapping  them  in  the  first  towel 
spoken  of.  This  is  continued  until  she  has  a  sufficient  number 
of  dressing  towels  ironed  for  each  dressing.  In  sterilizing  the 
towels  the  nurse  should  have  her  hands  thoroughly  clean. 

The  following  precautions  should  be  taken  when  you  are 
not  pressed  for  time :  You  can  steri,lize  your  cotton  and  towels 
by  rolling  them  up  and  placing  them  in  a  quart  fruit  jar, 
tight.ly  closed  and  boiled  for  three  hours.  Of  course,  the 
bottles  must  be  hermetically  sealed  and  removed  from  the 
boiling  water  while  the  water  is  still  hot.  If  the  bottles  are 
allowed  to  remain  in  the  water  until  it  cools  the  suction  will 
force  water  into  the  jars. 

I  have  NO  USE  for  a  nurse  who  SCORCHES  and  DE- 
STROYS the  linen  of  a  household,  nor  will  I  recommend  one 
who  does  so.  Nurses  should  never  sterilize  towels  by  putting 
them  in  the  oven  and  scorching  them,  as  this  is  the  common 
practice.  No  family  likes  to  have  two  or  three  dozen  towels 
destroyed  on  them  in  this  way.  Nor  are  they  thoroughly  sterile 
unless  scorched. 

The  nurse  should  have  supplied  at  the  bedside  a  pair  of 
scissors  and  dressing  forceps,  a  small  glass  syringe  and  a 
small  brandy  glass,  all  sterilized  and  placed  in  a  sterilized 
basin  containing  sterile  water;  she  should  supply  dressings 
as  ordered.    A  basin  for  soiled  dressings  will  be  of  great  use. 

When  the  nurse  is  ca,lled  on  to  do  the  dressing  she  should 
avoid  using  her  fingers.  She  should  at  all  times  use  dressing- 
forceps  whenever  possible. 

In  the  emergency  cases  when  the  time  for  preparation  is 
very  short  the  nurse  will  have  to  use  all  of  her  wits  to  prepare 
the  patient  as  best  her  training  has  taught  her.     She  should 


♦  25 

never  forget  to  supply  or  to  think  of  the  best  light  for  night 
work.  In  these  cases  we  must  take  risks  in  regard  to  asepsis 
which  cannot  be  permitted  with  ordinary  cases. 

As  a  rule  the  doctor  will  order  how  the  patient  should  be 
prepared;  when  he  fails  to  do  so  you  will  not  go  amiss  by 
following  such  directions  as  are  given  to  you  in  such  an  in- 
stitution as  this,  and  which  is  my  pleasure  to  tell  you. 

In  the  hospital  you  will  have  no  voice  in  the  selection  of 
the  operating  or  sick  room.  These  are  already  furnished.  It 
is  different  in  the  private  house.  When  the  doctor  is  present 
consult  him  as  to  the  choice  of  room;  when  not,  be  sure  to 
select  such  a  room  as  will  have  plenty  of  light  and  air,  but 
avoid  the  direct  sunlight  for  the  operation.  When  there  is 
no  choice,  and  there  is  direct  sunlight,  cover  the  windows  with 
a  sheet  during  the  operation.  A  north  light  is  best  for  al,l 
operations. 

Kemove  all  useless  furniture,  but  do  not  upset  the  whole 
house;  cover  the  large  pieces  with  sheets,  and  if  there  has  been 
no  time  to  remove  the  carpet  cover  it  with  newspapers  and 
sheets.  Avoid  stirring  up  the  dust.  Wipe  all  of  the  furniture 
and  woodwork  with  a  damp  towel.  The  temperature  should 
be  about  80  degrees  F.  You  should  clean  and  disinfect  all 
closets,  basins  and  bathtubs  near  the  operating  room;  this 
is  best  done  by  pouring  a  strong  hot  solution  of  potash  lye  into 
these  utensils. 

For  our  purpose  an  operating  table,"  such  as  has  been  de- 
scribed under  the  head  of  gynecological  examinations,  will 
do  very  well.  An  ordinary  kitchen  table  is  always  handy; 
let  it  be  thoroughly  scrubbed  and  cleaned.  Two  smaller 
tables  for  instruments  and  sponges  or  wipes,  two  buckets  for 
waste  water,  two  basins,  preferably  agate  or  tinware,  and 
one  porcelain  basin,  besides  a  soap  dish  for  the  patient  to 
vomit  into;  nail  brushes  shou,ld  also  be  procured.  The  por- 
celain basin  can  be  used  for  towels,  steeped  in  a  hot  bichloride 
solution.  The  two  basins  of  tin  or  agateware  should  have 
been  boiled  in  a  wash  boiler  for  ten  minutes,  and  one  can  be 
used  by  the  operator  to  wash  his  hands  in  during  the  operation, 
while  the  other  is  for  sterile  warm  water  for  the  purpose  of 
washing  up  the  patient.  This  will  supply  all  of  the  utensils 
that  may  be  wanted  in  this  direction. 

T^or  the  larger  operations  two  dozen  towels,  two  sheets 
and  a  clean  small  blanket,  all  recentlj^  sterilized.  Sterilized 
hot  and  cold  water  will  have  to  be  supplied  and  should  be 
prepared  in  this  Avay.  See  that  your  pitchers  are  thoroughly 
clean,  then  ,boil  them  in  a  wash  boiler  for  one-half  hour.  Fill 
a  tea  kettle  and  let  the  water  that  is  in  it  boil  for  ten  minutes, 
then  pour  it  into  your  boiled  pitchers.     They  should  now  be 


26 

covered  with  a  sterile  towel  and  set  in  a  safe  place  to  cool. 
Two  large  toilet  pitchers  full  of  water  will  be  sufficient  for 
most  operations. 

The  nurse  should  have  her  glass  catheter  boiled  ready 
for  use. 

Pr-jtect  the  floor  beneath  the  operating  table  by  spreading 
oilcloth  or  newspapers  over  it,  and  over  this  lay  the  sheets. 
In  the  room  adjoining  the  operating  room  you  should  have 
basins  of  water,  soap,  brushes  and  towels  for  the  surgeon's 
use.  AVliatever  antiseptics  he  may  want  to  use  will  be  or- 
dered by  him.  Thus  also  will  he  order  the  dressings.  If  none 
is  ordered  the  nurse  should  have  sterile  gauze,  iodoform  gauze, 
sterile  cotton,  and  a  many  tailed  or  plain  flannel  bandage 
ready.  She  should  be  provided  with  safety  pins  and  a  good 
pair  of  scissors.  When  the  surgeon  has  no  gown  you  may 
use  a  large  towel  recently  ironed  and  pin  it  to  his  suspenders. 
If  you  are  responsible  for  the  sponges,  count  them  and  re- 
count them  most  carefully.  Sea  sponges  are  rarely  used  in 
these  days.  When  napkins  are  used  they  should  be  care- 
fully counted,  and  each  one  accounted  for  before  the  wound 
is  closed.  A  napkin  or  sponge  left  in  the  abdomen  is  likely  to 
kill  the  patient.  In  this  hospital  every  napkin  is  known  by  a 
letter  and  a  number;  the  letter  is  changed  on  every  set  of 
thirty  naj)kins  in  such  a  way  that  no  two  nai)kins  in  the  house 
have  the  same  number  and  letter  on  it.  For  instance,  there 
is  but  one  napkin  known  as  0.  17. 

Every  nurse  should  supply  herself  with  shaving  appliances 
and  a  hypodermic  syringe.  She  should  see  that  alcohol  and 
brandy  or  whiskey  is  furnished. 

The  room  and  bed  for  the  patient  after  the  operation 
should  be  properly  prepared  for  her  reception  after  the  oper- 
ation. It  is  well  to  leave  the  patient  in  the  room  that  she  has 
been  operated  in.  The  bed  should  have  been  made  v/arm  by 
the  use  of  hot  water  bottles,  but  never  pack  hot  water  bottles 
around  your  patient,  as  severe  burns  have  been  caused  by 
such  Dractices.  If  the  room  selected  is  a  cheerful  and  quiet 
one  so  much  the  better. 

Ask  your  doctor  for  instructions  about  diet  and  the  use 
of  the  catheter. 

PEEPAKATION  OF  THE  PATIENT  FOR  SPECIAL 
OPERATIONS. 

1.— PREPARATION  OF  THE  PATIENT  FOR  EXAMINA- 
TION UNDER  AN  ANESTHETIC. 

The  patient's  bowels  should  have  been  moved  thoroughly 
with  fifteen  grammes  of  potassii  et  sodii  tartras,  to  be  given 


27 

« 

on  the  Dioi'uing  preceding  the  examination,  one-half  hour 
before  breakfast  and  liquid  diet  on  that  day.  On  the  evening 
of  that  day  she  should  have  a  hot  soap  bath,  including  a  sham- 
poo of  the  head  and  clean  linen.  On  the  morning  of  the  exami- 
nation she  should  have  two  large  warm  water  rectal  enemas, 
the  first  of  which  should  be  of  soapsuds  followed  by  plain 
water.  The  last  of  these  should  be  given  three  hours  before 
the  examination.  After  the  bowels  have  been  thorough,ly 
emptied  a  large  warm  vaginal  douche  of  soapsuds  should  be 
given. 

She  must  have  no  breakfast  whatever,  and  no  milk  for 
twelve  hours  previous  to  the  anesthesia.  If  the  anesthesia  is 
to  take  place  in  the  afternoon  she  can  have  a  little  black 
coffee  and  later  some  beef  broth. 

2.— PREPARATION  OF  PATIENT  FOR  RECTAL 
OPERATIONS. 

The  anus  and  vulva  shou,ld  be  shaved,  and  a  thorough  bath, 
shampoo,  etc.,  and  clean  linen  put  on.  The  bowels  should  be 
thoroughly  emptied.  I  prefer  a  calomel  purge,  which  is  given 
on  the  morning  of  the  day  before  the  operation  and  followed 
by  a  seidlitz  powder  two  hours  after  the  last  dose  of  calomel. 
The  following  is  the  formula  I  order  for  the  calome.I  powders: 

R. 

Calomel    0.6 

Sodae  Bicarb 0.3 

Sacch.  Alb 2.0 

M.     Div.  in  doses  No.  3. 
Sig.     One  powder  every  two  hours. 

On  the  morning  of  the  operation  two  large  rectal  enemas, 
the  first  of  which  should  be  soapsuds  and  the  last  plain  water, 
and  a  vaginal  douche  are  administered  as  has  been  noted 
under  the  foregoing  order. 

The  patient  should  have  had  a  liquid  diet  on  the  day  she 
took  tlu.'  calomel  powders  and  no  breakfast  on  the  day  of  the 
operation. 

3.— PREPxVRATION  OF  THE  PATIENT  FOR  DILATATION 
OF  THE  CERVIX  UTERI  AND  CURETTAGE. 

Are  the  same  as  number  one,  except  that  the  patient 
should  be  shaved  about  the  vujva  and  pubes,  and  the  calomel 
powders  given  as  in  number  two. 


28 

4.-- -PREPARATION  OF  THE  PATIENT  FOR  OPERATION 

ON  THE  CERVIX  UTERI,  THE  BLADDER, 

VAGINA  AND  PERINEUM. 

Should  be  the  same  as  under  number  three,  except  that 
the  patient  should  have  a  strictly  liquid  diet  on  the  day  pre- 
vious to  the  operation. 

5.— FOR   THE   PREPARATION   OF  THE   PATIENT   FOR 
ABDOMINAL  SECTION  AND  ALL  VAGINAL  OPER- 
ATIONS IMPLICATING  THE  PERITONEUM. 

All  patients  prepared  for  vaginal  operations  implicating 
the  peritoneum  should  also  have  the  abdomen  ttrepared  for 
an  abdominal  section.  She  should  be  in  the  hospital  or  under 
preparation  for  forty-eight  hours  previous  to  the  operation. 
On  the  first  day  she  should  be  given  calomel  and  seidlitz 
powders  as  under  number  two.  She  should  have  two  soapsud 
douches  and  a  hot  soapsud  bath,  hair  shampoo,  clean  body 
linen  and  clean  bed  linen  in  the  evening.  She  should  have 
another  seidlitz  powder  or  fifteen  grammes  of  potassii  et  sodii 
tartras  on  the  morning  of  the  second  day.  In  the  evening 
another  hot  soap  bath  and  clean  linen.  After  this  she  is  put 
into  a  clean  bed  and  a  soap  poultice  placed  over  the  whole 
abdomen  for  two  hours.  The  abdomen  is  then  thoroughly 
shaved  and  scrubbed,  especial  care  being  given  to  the  navel. 
The  same  can  be  said  of  the  vulva.  The  abdomen  is  then 
Avashed  with  ether  and  alcoho,l.  All  is  covered  with  sterile 
gauze,  which  is  kept  in  position  by  a  well-fitting  abdominal 
and  T   binder. 

On  the  morning  of  the  operation  the  patient  receives  an 
enema  of  warm  soap  water,  followed  by  one  of  plain  water,  the 
last  of  which  should  be  administered  at  least  three  hours 
before  the  time  set  for  the  operation.  If  the  second  one  con- 
tains fecal  matter,  a  third  or  fourth  may  be  necesssary.  A 
vaginal  douche  of  corrosive  sublimate  1-5000  follows.  A  large 
piece  of  gauze  or  a  towel  dipped  into  a  corrosive  sublimate 
solution  of  1-2000  is  placed  over  the  abdomen  and  vulva  and 
should  be  kept  in  place  for  tvv  o  hours,  that  is  to  the  time  of  the 
operation,  and  kept  in  position  by  a  well-fitting  abdominal  and 
T  binder.    The  patient  is  then  dressed  in  flannel  clothes. 

During  the  first  day  of  the  preparation  the  patient  should 
have  only  such  food  as  is  easily  digested  and  will  produce  but 
little  gas  or  residue.  A  patient's  idiosyncrasy  must  be  taken 
into  consideration.    As  a  rule  she  will  do  well  with  a  broiled 


29 

chop  or  steak,  wheat  porridge,  milk,  tea,  coffee,  beef  broths, 
chicken  broths  and  cooked  rice.  Avoid  all  vegetables,  fruits 
and  sweets. 

On  the  day  previous  to  the  operation  liquids  only  are  ad- 
missable.  On  the  day  of  the  operation  she  should  have  noth- 
ing if  the  operation  is  done  early  in  the  morning,  otherwise 
she  may  have  a  cup  of  beef  or  mutton  broth  with  barley. 

The  urine  should  always  be  drawn  on  the  first  day  for 
examination. 

6.— PREPAEATION  OF  PATIENT  FOR  AMPUTATION  OF 
THE  BREAST. 

The  nurse  should  begin  preparations  twenty-four  hours 
before  the  time  set  for  the  operation.  The  patient  should  have 
a  calomel  purge  and  a  seid,litz  powder  as  in  number  two.  A 
liquid  diet  and  a  hot  bath,  shampoo  and  clean  linen  on  the 
evening  preceding  the  operation.  A  soap  poultice  should  be 
placed  upon  the  breast,  shoulder,  upper  part  of  the  arm  and 
axilla  for  two  hours  after  the  bath,  when  it  is  removed  and 
the  breast,  axilla  and  arm  are  thoroughly  scrubbed  and  shaved. 
All  is  then  washed  off  well  with  ether  and  alcohol  and  covered 
with  sterile  gauze,  which  is  kept  in  position  by  a  breast  binder 
and  shoulder  straps. 

On  the  morning,  two  hours  before  the  operation,  a  cor- 
rosive sublimate  poultice  1-2000  is  placed  over  the  breast, 
shoulder,  upper  part  of  the  arm  and  axilla.  She  is  to  have 
no  breakfast,  if  the  operation  is  done  in  the  morning,  other- 
wise she  may  have  beef  or  mutton  broth  with  barley. 


THE  AFTER-TREATMENT  OF  THE  PATIENT. 

The  care  which  the  nurse  gives  to  her  patient  should,  among 
other  things,  consist  of  keeping  a  careful  record  of  everything 
going  on  about  her.  A  record  of  the  temperature,  pulse  and 
respiration,  at  intervals  of  three  hours;  the  quantity  of  food 
given,  amount  of  urine  passed  or  drawn,  the  escape  of  flatus, 
the  hours  of  sleep  or  restlessness,  medicine  given,  condition  of 
the  skin,  mouth,  change  of  dressings,  baths,  etc.,  are  all  very 
important.  She  should  also  note  the  total  amount  of  food 
that  has  been  given  in  the  twenty-four  hours,  and  the  quantity 
of  urine  passed  or  drawn  in  the  same  time. 


30 

It  is  wise  to  record  the  amount  of  urine  passed  for  at  least 
three  times  twenty-four  hours  after  the  operation,  unless  spe- 
cial orders  for  its  continuance  is  given.  The  patient  may  pass 
her  urine  if  she  can. 

Anything  worth  while  recording  should  be  recorded  at 
the  moment  it  occurs  and  the  memory  never  trusted. 

In  all  rectal  operations  a  well-fitting  T  binder,  with  a 
suitable  dressing  and  compress  over  the  anus,  is  desirable. 
The  dressings  and  compress  should  be  renewed,  the  parts 
cleaned  after  each  catheterization  or  defecation.  It  is  wise 
when  a  cathartic  has  been  ordered  to  inject  from  150  c.  c.  m. 
to  200  c.  c.  m.  of  sweet  oil  into  the  rectum,  as  it  assists  ma- 
terially in  the  painlessness  and  ease  with  which  the  movement 
passes  over  the  raw  surfaces.  It  is  wise  to  inject  this  with  a 
soft  rubber  catheter  of  medium  size,  to  which  is  attached  a 
funnel  or  syringe.  The  temperature  of  the  oil  should  be  from 
95  to  100  degrees;  this  can  be  heated  to  the  desired  temperature 
by  placing  the  vessel  containing  the  oil  into  another  vessel  con- 
taining hot  water.  As  soon  as  the  bowels  have  moved  the 
parts  should  be  thoroughly  cleansed  with  pledgets  of  sterile 
cotton  and  sterile  water;  if  necessary,  soap  may  be  added. 

It  is  not  easy  in  the  rectal  cases  to  take  the  temperature 
in  the  bowej.  It  is  therefore  best  to  take  a  mouth  temperature 
or  a  temperature  by  the  vagina. 

In  operations  about  the  vagina  or  the  perineum  the  ex- 
ternal genital  should  be  kept  scrupulously  dry  and  clean. 
Douches  should  not  be  given  unless  ordered.  In  the  perineal 
operations  small  pieces  of  gauze  should  be  placed  on  both 
sides  of  the  vulva  and  sutures.  These  should  be  frequently 
changed,  certainly  often  enough  to  keep  the  parts  dry. 

The  movements  of  the  bowels,  after  perineal  operations, 
whether  they  have  been  complete  or  incomplete  tears,  should 
be  urged  after  forty-eight  hours;  in  both  cases  from  130  to 
200  c.  c.  of  oil  should  be  injected  into  the  rectum.  This  is 
most  necessary  in  the  after-treatment  after  the  operation 
for  complete  laceration  of  the  perineum.  In  this  operation 
the  patient's  bowels  should  be  moved  while  she  lies  on  her 
left  side,  the  nurse  taking  care  of  her  in  the  following  way: 
The  patient  should  be  placed  on  her  left  side  with  a  sma,ll 
pillow  under  her  head  and  a  pus  basin  pushed  well  under 
the  left  buttock  after  both  knees  have  been  well  flexed  and 
the  bed  protected.  When  the  inclination  comes  the  nurse 
supports  the  perineum  with  her  left  hand  by  pressing  the 
flesh  of  the  right  buttock  just  above  the  gluteal  fold  to  the 
left  side,  while  the  right  hand  raises  the  flesh  of  the  right 
side  above  the  anus  outward.  This  opens  the  anus  without 
putting  any  pressure  on  the  perineal  wound.     If  the  move- 


31 

ment  is  an  easy  one  it  is  not  necessary  to  repeat  this  manipu- 
ilation,  and  the  second  movement  may  be  had  on  the  bed  pan. 
A  movement  should  be  secured  once  in  two  days. 

When  the  urine  is  drawn  the  thighs  should  be  raised  at 
right  angles  to  the  body.  The  meatus  urinarius  will  become 
quite  apparent.  When  the  patient  passes  urine  voluntarily 
the  parts  should  be  rinsed  with  sterile  water  and  wiped  dry 
with  pledgets  of  sterile  absorbent  cotton  or  gauze,  using  a 
sterile  dressing  forcep  to  handle  the  pledgets  instead  of  the 
fingers.    Take  the  temperature  by  the  rectum. 

In  all  of  the  cases  thus  far  spoken  of  the  patient  should 
be  placed  on  a  .liquid  diet  for  two  days,  except  in  the  rectal 
cases,  when  it  will  be  wise  to  give  a  liquid  diet  for  five  days. 

In  the  abdominal  sections  we  usually  give  our  patients  no 
drinks  until  vomiting  ceases.  One  can,  as  a  rule,  say  that  all 
vomiting  ceases  after  six  or  eight  hours;  we  then  give  a  tea- 
spoonful  of  hot  water,  as  hot  as  the  patient  can  take  it,  every 
ten  minutes  for  tw^elve  hours.  Hot  barley  water  (three  table- 
spoonfuls  of  washed  bar,ley  in  a  quart  of  water,  boiled  for 
three  hours  and  kept  at  a  quart),  and  hot  water  alternately 
every  ten  minutes  may  be  given  for  the  next  twelve  hours.  If 
during  this  time  the  patient  complains  of  great  thirst  a  warm 
normal  salt  solution  (6  parts  of  salt  to  1000  parts  of  water), 
may  be  slowly  injected  into  the  rectum  in  quantities  of  200 
c.  c.  m.  once  in  three  hours.  When  the  barley  water  and  the  hot 
water  has  agreed  with  the  patient,  hot  milk  is  added  to  the 
diet  in  tablespoonful  doses  alternately  with  the  barley  water 
every  twenty  minutes.  As  soon  as  the  patient  has  passed 
gas  per  rectum  she  takes  one-half  teacupful  doses  of  the  food 
as  she  desires,  but  not  less  frequently  than  every  hour.  When 
she  sleeps  she  should  not  be  disturbed  for  anything.  Beef 
and  chicken  broth  with  barley,  rice  or  oatmeal  can  be  added 
to  this  diet  on  the  fourth  day. 

The  urine  should  be  drawn  once  in  six  or  eight  hours  unless 
the  patient  can  pass  it  herself.  While  there  is  no  serious  ob- 
jection to  having  the  bowels  move  earlier  than  the  fifth  day, 
1.  e.,  four  times  twenty-four  hours  after  the  operation,  it  has 
been  my  custom  to  do  so  for  many  years.  I  usually  order  a 
teaspoonful  of  Kochelle  salts  every  hour  in  a  table-spoonful  of 
water  until  the  bowels  move.  When  the  patient  is  nauseated, 
or  when  she  vomits,  I  stop  the  Rochelle  salts  by  mouth  and 
order  two  tablespoonfuls  of  Rochelle  salts  in  500  c.  c.  m.  of 
water  to  be  given  by  enema.  From  the  time  that  her  bowels 
move  until  the  end  of  the  week  the  patient  takes  a  liquid  diet ; 
after  that  she  may  take  solids.  The  bowels  are  moved  every 
second  day,  and  the  patient  may  be  allowed  to  sit  up  on  the 
eighteenth  day. 


32 

In  exceptional  cases  you  will  be  asked  to  manage  the 
drainage  tube. 

The  drainage  tube  is  placed  in  the  lower  end  of  the  wound 
down  into  Douglas's  Cul-de-sac.  After  the  wound  is  closed  and 
covered  by  such  dressing  as  suits  the  surgeon,  a  piece  of  rub- 
ber dam  is  slipped  over  the  flanged  end  of  the  tube,  then  a 
small  piece  of  gauze  is  placed  over  the  tube  and  the  rubber 
dam  folded  over  this;  the  nurse  now  will  be  directed  to  empty 
this  tube  at  various  intervals,  and  it  is  done  in  the  foljowing 
way:  Sterile  dressing  towels  are  placed  around  the  rubber 
dam  and  the  latter  carefully  unfolded.  A  small-size  rubber 
tube  about  14  inches  in  length  to  which  has  been  attached 
a  glass  syringe,  all  thoroughly  sterile,  is  carefuljy  introduced 
into  the  bottom  of  the  glass  drainage  tube.  By  withdrawing 
the  piston  of  the  syringe  the  fluid  in  the  drainage  tube  is 
withdrawn  into  the  syringe.  The  rubber  tube  is  now  with- 
drawn and  the  fluid  emptied  out  of  the  syringe.  This 
maneuver  is  repeated  until  the  drainage  tube  is  thoroughly 
emptied.  A  piece  of  iodoform  or  corrosive  sublimate  gauze  is 
placed  over  the  drainage  tube  and  the  rubber  dam  carefully 
folded  over  this.  The  whole  apparatus  is  held  in  position  by  a 
towel  or  napkin  pinned  over  it.  This  emptying  of  the  tube 
is  done  once  an  hour  for  the  first  twenty-four  hours  and  less 
frequently  during  the  next.  Once  in  six  hours  the  tube  is 
given  a  slow  twist  so  as  to  free  the  openings  in  the  lower  end. 


